Learning Medicine

The Ultimate Guide to Study Skills in Medical School

Friday, February 24, 2012

Studying Pathology (And My Anki Deck)

Update 2015-05-28: I've co-written a comprehensive guide to learning in medical school that incorporates Anki with a host of other evidence-backed study hacks. This book is an essential companion to the ideas in this post. Disclaimer: The recommendations below are for how to best learn key subjects in med school. In fact, any study advice I give on this blog or elsewhere is always with the aim of learning for the long term. For that should be the primary goal in my mind. However, I just want to be clear: my recommendations are not geared toward destroying class exams. If that is your goal, you need to really pay attention to lecture slides and class material and old exams and such. I also want to be clear about my intentions and own abilities. I'm a regular med student who just likes to share ideas. I'm know there a lot smarter people in med school then me. In fact, I'm sure of it. But I think I've found things that work well and I want to share that information with anyone who will listen. Always be critical and always evaluate whether what I'm saying will suit your needs and abilities. Thanks for checking out Dr. WillBe.

I've been meaning to write this post for a while. With the first years at my school starting pathology last week, I thought now would be the right time.

Pathology is perhaps the most important preclinical subject. Pretty much, this is medicine. You've learned about how the body functions normally. Now it's time to see what happens when things go awry. Spending the time to learn pathology right will pay great dividends in your future clinical career. Having solid knowledge of the diseases that afflict people and their underlying mechanisms is a requisite to being an excellent physician, in my opinion. It's what separates doctors from technicians. We understand the why as much as the what. And with that understanding, physicians can push the boundaries of medicine rather than merely practicing it.

OK. Enough of my soapbox speech. Clearly I think Pathology has intrinsic value, but more practically, Pathology is the most heavily represented subject on the USMLE Step 1 exam. If you want to do well on Step 1, you need to know Path. And know it cold. There is no way around that. That's reason enough for most med students to take Path seriously.

How does one do that? Well, that's what I'm going to talk about today. As in my other posts, I'll discuss what I actually did and do in my own studying, and then I'll suggest what I would have done if I could do it again.

Methods
First, let's talk about methodology. I'm beginning to sound like a broken record, but I can't help singing the praises of Anki, a spaced-repetition flashcard program. I've benefitted so much from this tool that I want to tell everyone I know about it. You can read about the how and why of SR and Anki here and here. Needless to say, I think Anki is awesome for pathology and it has been the core method for my study of the subject. Actually, of all the subjects in med school, I think Anki is most important for Path because of the vast number of facts and ideas that one has to commit to memory.

For Path - and pretty much every other subject I study using Anki - the process goes like this.

Read - Make cards - Immediately review cards after reading - Repeat

It's that simple. What makes Anki challenging for many students, however, is the fact that you need to continue to review old cards even while you plow through copious amounts of new stuff. It's a struggle, I'll admit, but it's the only way to keep all the hard wrought information you learned already in your head. It get's better over time, and when you stop adding new material, the number of old cards you have to review gets smaller and smaller.

Before I go on, I want to clear up a misconception that people have about Anki. Flashcards ARE NOT A PRIMARY LEARNING TOOL! (sorry for the caps, but I feel like I need to scream this). I don't learn from looking at a bunch of disjointed flashcards. Nobody does. And if they do, they're probably doing a pretty poor job of learning. My primary learning tool is a book. I want a story. I need to see facts in context. We all do. That's not what Anki is for. Anki is for retention of information, not first-pass learning. You use it AFTER you've learned and understood something. This is one of the cardinal rules of SR best practices. Don't make a card for something until you understand it.

Many people will crush a 50 page chapter in Robbin's Pathology or something similar and then close the book, deluding themselves into thinking that just because they scanned their eyes over that much text, they actually are going to remember most of it. Then they go to take a test or something, and they find out that they only remember about 10-20% of what they read, if that.

Maybe there are 1 or 2 beasts in medical school who read massive texts without any other consolidation strategy, but for the rest of us, there needs to be some way to retain and maintain the knowledge we gleaned from our primary studies. Lots of cognitive research - and just good common sense- confirms that repetition and review is essential to long term retention. Moreover, the spacing of reviews over time with increasingly longer intervals is key. And that is what Anki gives us in a way that we could never do before. My personal path deck (see below) has over 6000 cards in it. Those facts are all pulled from the sources that all medical students use to learn path. If the number is daunting, that's because it is. There are just that many factoids to remember. Without a digital SR program like Anki, however, I could never make and manage that many physical flashcards. It's awesome to be a student in 2012 :)

So, bottom line. All my recommendations for studying path, and pretty much any other subject in medical school, depend on Anki. I don't believe in binge and purge. Slow and steady wins the race. Come time for Step 1, if you've used Anki diligently and continuously throughout medical school, there will be no need to have to go back and relearn most of 1st and 2nd year in the 4-6 weeks allotted to you for Step 1 study. Rather, all that knowledge you gained will be burned permanently in your mind, ready to access when needed. Then, instead of focusing on content review, you can spend your time mastering the information by doing tons of questions and problems. This is what I'm doing for my own Step 1 strategy. So that's the point of all this. To not forget. To master the material. To build a rock-solid foundation for rest of your clinical career. And to destroy Step 1.

Resources
This is the part that you've probably been waiting for. You're saying to yourself, "OK WillBe, I know you're an Anki zealot. I get it. I'll use it. But what should I make those cards from? What should I study?"

I'm glad you asked.

Because Pathology is such an important topic, there are a lot of resources to choose some. Some are better and more appropriate than others.

Let me first give a list of all the ones I know about and then we'll talk about which ones you should be using.

GeneralFirst Aid for the USMLE Step 1 - the gold standard for Step 1 review. Getting through FA should be the minimum goal you achieve in your studies. Everything in this book is high yield. This book might just seem like a litany of bulleted factoids (and it is), but it's surprisingly helpful. There are things in here that don't show up in any other source.

TextbooksRobbins and Cotran Pathologic Basis of Disease, 8th ed ("Big Robbins") - the Bible of Pathology. This is the book that Pathologists learn from. Med students for decades have used Robbins as their go-to source for path. Most people use it now as a reference, but some students use it as their primary source. Depending on how much time you have and your willpower, you could slog through all of Robbins in your pathology course.

Robbin Basic Pathology 8th ed (9th coming out in April) ("Middle Robbins") - A pared down down version of Big Robbins. This book is more approachable, and more appropriate for medical students learning pathology. The core concepts are the same as in Big Robbins, but there is less information about the histopathology and sometimes less detail in the discussions of pathogenesis. Still, at 946 pages, Basic Pathology is no push over.

Review BooksRapid Review Pathology 3ed ("Goljan") - In the last few years, this 'review' book (and I put review in quotes because this book is 600+ pages) has emerged as the favorite of medical students. The author, Edward Goljan, is sort of a legend amongst med students because of this text and the accompanying bootleg audio lectures. This book has everything one needs to crush the pathology on Step 1. It's written in bulleted format with high yield factoids in the margins. Many students bypass the above textbooks and learn directly from Rapid Review. This book has proven it's effectiveness over the years, and that's why it continues to be the favorite every year. I'm not so sure though that it's the best anymore (see below). Pathoma may have knocked the king off the hill.

Fundamentals of Pathology by Dr. Sattar (Pathoma) - Pathoma is a new resource that just came out in April 2011. It is a series of video lectures and a review book made by Dr. Hussain Sattar from the University of Chicago. In less than a year, Pathoma has become the hottest Pathology resource around. I learned about it after I was already done with Pathology, but I've been using it to fill in the blanks since then. There is 35 hours of extremely high-yield, high-quality videos and an accompanying textbook that is equally impressive. And all this comes at $100, which is an amazing deal when you think about it. Many have dubbed Pathoma 'the New Goljan'. I think this is correct. The book is more concise. The videos give more explanation. Dr. Sattar is just a gifted teacher. The difference between Pathoma and Goljan is that the latter has proven itself over the years as a tool for success. Students have used it for Step 1 and have done very well. Pathoma, on the other hand, has not had that kind of track record yet. Many med students rave about it on Student Doctor Network and some have used it for Step 1, but not as many as have used Goljan. So that's the downside. Using Pathoma is using an unproven tool. But that shouldn't deter you.

I've used all the canonical resources. I've read Robbins. I've read First Aid. I've read Goljan. And I've been reading Pathoma and using the videos. So I know them all. Pathoma has everything that First Aid has and more. So right there, Pathoma is already as good as First Aid, which people trust without a doubt. There is significantly less material in Pathoma than Goljan. But it is questionable whether that means much. I'd say everything in Pathoma is high yield. Goljan, despite being a review book, has lots of miscellaneous info that may or may not be useful on Step 1. In fact, I've heard it said that Goljan not merely for Step 1 (although that's how it's used) but also for Steps 2 and 3. So that explains some of the difference.

So while Pathoma hasn't stood the test of time yet, I think in a few years it will completely replace Rapid Review. Because Pathoma is higher yield, better written and more approachable than Goljan, I think one would be better served to use it. One stands a better chance of actually getting through all of Pathoma than Goljan too, which is significant. Better to have a complete view with good detail rather than an incomplete one with lots of detail in some areas but none in other. If one knew everything in Pathoma inside and out, I think he'd know more than enough pathology to excel in class and on the boards.

Plus the videos are excellent. Until now, everyone has used the bootleg audio from Goljan. I never did like these very much. The quality is poor. There are a lot of jokes and tangents. Plus, there is no visual component. And did I mention it's bootleg? Pathoma, on the other hand, is a whole library of video clips that one can watch as well as listen to. The visual component is key. And with the book, you can read along.

I am really enthusiastic about this new resource, in case you couldn't tell. I wish it was around when I was learning path the first time.

* Full disclosure. I have no ties to Pathoma. I've spoken to Dr. Sattar once just to tell him I loved his work and to keep it up. That's it. I want to support a good thing when I see it and so that's why I'm promoting it here.

Here is a sample video. Check it out and see if this style of teaching appeals to you.

BRS Pathology - This used to be the go-to source for Pathology review a couple of years ago, but it's since been replaced by Goljan. I really didn't use it, so I can't say much about it. Some people like it. The BRS format is familiar and effective. It's less dense than Goljan, bigger than Pathoma and First Aid. I think with Pathoma on the scene, BRS will become less popular even, but I don't think it's a bad book. If you like BRS books, check it out.

Question BanksRobbins Review of Pathology - This is a companion book to Robbins. It's all questions testing your knowledge of path. My classmates used this book to study for our exams and we were well served. It's quite detailed, much more so than Step 1 level pathology. The nice thing about it is that every question references a section in the Robbins family of books so you can go read when you get a question wrong. I think this book is worth having.

USMLE World Step 1 - Does this even need an explanation? USMLE World is recognized as the best source for Step 1 prep questions. There is debate about whether or not you should use these questions while still learning material. Some people think you should save UWorld for when you're doing dedicated study for Step 1. I think this is a sound idea. There are plusses and minuses to both. The idea is that if you do UWorld too early, you'll forget what you learned and waste questions. That may be true if you do the binge-and-purge thing. But if you're using Anki, you could use UWorld and make cards for the explanations and thus remember everything. UWorld is as much a learning tool as a testing tool. There is stuff in here that might only show up in Big Robbins or maybe not even. So using UWorld and Anki together makes sense. This is what I do in fact. I've been going through the q's and making cards for things I didn't know so that they're in my review deck.

Kaplan Step 1 Qbank - Another USMLE q bank. I haven't used it. I might though. Word is that the questions can be esoteric at times. Not as high quality as UWorld but people use Kaplan while they're learning so that they don't waste the good stuff (UWorld) before they're Step 1 review time. This isn't a bad idea.

USMLERx - Questions made by the First Aid authors. It's like being pimped on First Aid. I don't think it's bad. I haven't used it much.

Putting It All Together - An Optimal Sequence
So we've covered the methods and the sources. Now how do we put it together? What is the optimal way to learn pathology?

As I've said before, I think learning complex subjects like Pathology is best done in layers. What I mean is, first you want to get an aerial view and become familiar with the landscape. Then fly a little lower in see some detail. Then, zoom in even further and examine the nitty gritty. Studying this way makes the learning more meaningful and effective. If you zoom in to the little stuff right from the get-go, you tend to lose the forest for the trees. That's not good. The detailed stuff makes much more sense and sticks better once you've mastered the big ideas.

I'm recommending here my preferred sources. This is basically what I did. As I said before, when I was first learning, I didn't have the benefit of Pathoma. So my experience has been to back track. Everything that I'm suggesting I've done myself. I just didn't do it in that order. The order I'm giving is the ideal one that I would have followed if I had known better.

Step 1 - The Aerial View
- Watch the relevant Pathoma video(s) at 1x speed
- Follow along in Fundamentals of Pathology
- At the end of the video, make Anki cards for every nugget in Fundamentals
- Cross-reference with the corresponding section of First Aid and make a card for anything not covered in Pathoma
- After making cards, immediately review them

Step 2 - Zooming In
- Read the same material in Robbins Basic Pathology
- Capture any high-yield/relevant factoids that you didn't get from Pathoma. Use your judgment here. You need to decide what's worth remembering and what's not. This is an art that is learned from experience.
- After making cards, immediately review them.

Step 3 - The Microscope
This part is optional. If you're the sort of person who really likes fine detail (or perhaps your class exams require this), you can go a step further.
- Read corresponding section in Big Robbins
- Capture factoids that you didn't get from any other source
- After making cards, immediately review them

Step 4 - Refining
- After having completed an entire topic or chapter (say Cardiac Pathology), use USMLE World or Kaplan or USMLE Rx. Use the questions to help you integrate all the information you've learned.
- Make cards for the ones you get wrong and/or the factoids that you don't already have in your set

You might be wondering when you should be doing all this. My advice is to spread this out as much as you can. So for example, I would do Step 1 on Monday. This should take you the whole day. If it's a particularly large chapter, spread out Step 1 over two days.

On Day 3 do Step 2. Then on Day 4 do Step 3. Take a break on day 5 or catch up on any part of the prior steps that you didn't get to. Remember that you're going to have all of your prior Anki reviews from other subjects coming due too. So make time in your day for that.

Then on the weekend, you can do Step 4 and do some integration questions from UWorld or elsewhere.

How you carry out this sequence will depend a lot on your class requirements, your own learning pace and style and your time commitments. If you notice, I say nothing about studying from lecture slides. That's because I don't think class material is particularly good. If you go to a P/F school, you can follow my suggestions closely. If you don't do P/F, you'll need to figure out how to satisfy your class requirements. You might have required attendance or something like that. I want to be clear. PASSING YOUR CLASSES IS THE MOST IMPORTANT THING. This is just the reality of medical school. Although we'd all probably love for med school to get out of our way so we can learn medicine, the fact remains that passing your med school classes is necessary. So don't jeopardize that by completely disregarding class if you don't have that luxury. With that said, I'm certain that every medical school is in some way, shape or form covering the same material. Robbins is what your professors use to make their lectures. So if you do as I suggest, you're not going to miss anything. But what is emphasized by your class and what is emphasized by Step 1 are often not one and the same. Just keep that in mind.

Goal Setting
In all of this, you need to decide what you can handle and what you want out of your education. School is tough, and sometimes for all the wrong reasons. Mandatory classes, clinical skills classes(i.e. "tell me about your feelings"), busy work, and sundry other obstacles get in our way when trying to learn. That's just the way it is. So be realistic about what you can achieve.

I think a necessary, feasible and totally effective goal would be to cover First Aid and make cards for all of First Aid. That is the minimum goal. First Aid is not everything you need to know for Step 1, but it's a very large chunk of it. At the end of your preclinical courses, wouldn't it be great to have at least 50-60% of what you need to know down cold? If you aim for knowing 100% of everything, you'll get discouraged and likely quit this whole project and remember even less. Maybe like 20%. Be willing to compromise and be flexible.

My Pathology Deck and More
Disclaimer: I am sharing this deck because I want help other medical students learn pathology. I think making one's own cards is a valuable exercise and is superior to using someone else's, but I recognize that for a lot of people, this task is too much to handle. It's enough to turn people away from using Anki all together. So, I'm offering my cards as a compromise. If using my cards helps people learn Pathology and it encourages use of a system I really believe in (Anki), then I'm a happy man. I put hundreds of hours into building this deck but I see no reason why I should be the only one to benefit. I would have had to make these cards regardless, so why horde them all for myself? All I ask is that you give credit where it is due; if you share these cards with your classmates or anyone else, just let them know where they came from.

Also, I am almost certain that there will be some errors in these cards. There are over 6000 of them. I've done my best to ensure the accuracy and quality of my deck, but some errata have certainly slipped through the cracks. This is true of every learning resource, from First Aid, to Robbins. Please double check the material and I welcome you to post in the comments section any errata so I can fix my own deck. I'll periodically update the files with those improvements and any additions that I make.

A word on the content... This deck is nearly complete. It's covered all the pathology of First Aid. There are tidbits from Pathoma for things not covered by First Aid. There is a lot of Goljan. There is also material related to Big Robbins and from USMLE World. The only subject that needs a little more work is Female Pathology. That's about it.

Feel free to add your own cards to this deck once you take it down from Dropbox. If you feel so inclined, share those updates here by posting links so other people can benefit.

Happy Studying!

Update (04.24.13)
The Pathology deck has been revamped and updated, and is now for sale here on the site. You can find it here: DrWillBe Pathology Anki Deck

It depends on how many cards you make. If you're extremely 'stingy' with card making, then maybe you'll just have 20 cards. It depends on what you judge to be card-worthy. If you want to lessen your burden and you only want to reserve cards for the super duper high yield factoid, then you may be able to get away with 20 new cards.

But in all likelihood, you will make a lot more cards than that since there is just so much to remember. One way to lessen your daily load is to spread out your readings so as to make your card review manageable. The other is to just do more cards per day. I set the upper limit at 100 new cards/day. If you do much more than that, you're going to get overwhelmed and they'll all come due at the same time. Not good.

Having read through a lot of what you have written, I think we learn things similarly. I really like the idea of using Anki as much as I can, because so many things about it seem superior to a lot of 'traditional' methods of studying (and the way that I have learned stuff up to this point).

If you were me, how would you prepare from the start? Incorporate First Aid from day 1 of school, making cards from FA of topics that I'm covering in class? Sorry if you have covered this somewhere else and I just haven't seen it. Some of the med school lingo is unfamiliar to me.

Hey, thanks so much for the deck and the tips! They are so helpful. I noticed that the media folder for microbiology in Dropbox had corrupt images. Considering how helpful the deck has been to me, I hate asking the next question, but would it be possible for you to re-upload that media file? If it's not too big of a hassle I would extremely appreciate it. :)

I think Spaced Repetition (Anki) works for just about everyone because it is consistent with the way our brains work. That's the basis for all of this. I sometimes wonder how other people study without cards or questions of some sort. God bless them if they can just read a dense book chapter and retain all that information. But for the rest of us, we need good tools. Anki is one of the best I think.

As to First Aid from day 1, I would say yes. Absolutely. Conventional wisdom goes something like this: "Oh, dont' worry about FA in first year. You're going to forget all that anyway. Just focus on class. Or maybe annotate. But don't worry about First Aid just yet." If we presume that you're going to forget a lot of stuff, then yes, First Aid might well be a waste of time. But with a spaced repetition flashcard program, First Aid from day 1 makes total sense. As you go through your class studies, make cards to capture everything relevant in First Aid. Most likely there will be great overlap between First Aid and your classwork. No doubt your class will go more in depth. But that level of detail will not be worth your time to capture in cards, I think. First Aid is a good baseline goal for any medical student using Anki to aim for. Anything more is bonus. But only do as much as you can manage without getting overwhelmed.

Hi. I love your flashcards. Thank you. Will you describe how pleased you have been with your retention of basic science now that you are a third year? Do you still use your Step 1 flashcards even though you've moved on to Step 2 studying? What made you stop using gunner training? Sorry for so many questions, but I use pathoma for the aerial view before lectures, anki for lecture note-taking, and gunner training for longevity. I am sad I did not think of making pathoma anki cards back in August!

Overall, I'm very pleased with my retention. I believe I recall information with far great ease than I could ever do otherwise. But because there are not 2 me's and I can't run a controlled experiment, I can't say what life would be like without Anki. I don't even know. I can just tell you how I feel about my own abilities.

I haven't taken step 1 yet. Actually, we do our clinical year before step 1 at my school. So I'll do it at the end of this year. I've been doing my cards diligently, every day so I don't forget stuff from the classroom. I feel that I have a strong command of that info. I've begun doing USMLE World and without any other studying besides my daily card load, I'm averaging about 75-80%. From what I can tell, that's solid performance. So that's one objective measure of how the cards are helping.

I'll let you know how I fare on Step 1 when I take it in Oct. This is an experiment, and I'm taking a risk by not following the typical path. But I think the rewards, and the experience, are worth the risk.

I stopped using GT because I realized that it was redundant. GT is a lot of First Aid material. For people who don't want to make their own cards, it's a nice option. But for someone like me, it makes no sense. Anki is free and I think the spacing algorithm is superior. I can make my own cards. i can't do that on GT. Also, I own these cards and I won't lose them if I don't pay a prescription. Finally, with Anki, I can add whatever media I want and fashion the cards in the way I want. I think there is an optimal style to write questions, and GT often doesn't follow that. So for all those reasons, I stopped doing GT.

Don't worry about not getting the Pathoma facts into your cards. Whatever you've got is likely satisfactory. And, if you want, take from my 6000 cards and add to your own deck whatever you don't have. I haven't done all of Pathoma, but most of the info is there from FA, Goljan and Robbins.

Hi again. Thanks for such a detailed answer. I actually didn't have time to make my own flashcards so GT is right for me for Step 1 (I can't absorb FA by diffusion), and our lecturers don't even get consistently close to covering most of FA. I LOVE tweaking the Anki algorithm. I am using it to memorize H&P before we get dropped into clinic next week.

Dr Willbe, I have downloaded ur usmle flash card and they are aaamazing. the immunology, microbiology, and pathology doesn't work though. would it be possible if you post a new pathology deck for everyone??

Hi,What problem are you having? You need to download the flashcard files and then use them in Anki. Do you have Anki? Download at ankisrs.net. I tried the files this morning. No problem. hope that helps.

@ 11:09 PM. I'm glad you're enjoying the decks! That was my hope. The media for the microbio deck is corrupted for me too. Something happened with Dropbox and Anki and a couple of months ago I lost all that media. It sucks. I'll update my post above to let others know. And i'll take down the microbio media. I'm sorry. But everything else works.

Many say that a lot of the value from flashcards comes actually making them. I'm about three months away from taking Step 1 and although I made my own Pharm dec, I was considering using your other ones instead of making my own. However, I'm just concerned if I'll get the same benefit as you given how much time I'll have to start putting in for your decks (since it will be my first time seeing the cards).

There is value in making your own cards. It makes you a sharper reader because you have to glean points out for card making. You can't mindlessly type away.

With that said, the magic of Anki is the testing. I'd say 75% of the value comes after you make the cards. There is this widespread belief that the act of writing something out or making notes or w/e, is a good way to learn. Self-evaluation and forced recall is where the brain has to work hard, not in writing things out.

So even using someone else's cards would still be useful. But I wouldn't want to learn from cards. See what I wrote above. Learning from cards is not effective. You still need to read or watch a video. The cards are for afterwards, for retention.

Anki is for the long term. It can help for short term cramming too, but it's really for longer periods of time. So for Step 1 that is 3 months away, I don't know that doing my cards in a regular manner would be advisable. Definitely not the path deck. Maybe the pharm.

You have 2 options I'd say

(1) Use the 'cram' function to do some self-quizzing whenever you feel like you need it. In this way, you're not adding cards to a review schedule. You're doing them ad hoc. this is like the way people normally use flashcards. Crush them when you need them. The self testing is still useful, but you won't get the long term retention benefits.

(2) Your other option is only put cards into review that you don't know really well already. Do lets say you're going through my path deck for the first time. You get something right and it's easy for you. Normally, we would rate that card and bank it for the future. You don't have that luxury right now though. If you get something right on the first shot, you clearly know it well enough. So instead of banking it, suspend it so you never see it again. In this way, you might only end up having 500 of the 1500+ pharm cards in review. This way, you're only seeing the things you didn't know already.

Neither of these options is the optimal use of SR, but given your time constraints, it could work. But do what works for you. I tell people all the time. Don't become a slave to a methodology that doesn't work for you just because it seems attractive or more efficient. The best method is the one that works.

Your blog and posts are awesome. Thank you for taking the time to share what you've learned about learning strategies.

I agree with your advice about making your own cards if you have the time. It provides a check on mindlessly reviewing information you either don't understand or don't even need to put into the SRS software.

I don't start med school until next Fall, but I'm currently experimenting with using FullRecall versus Anki.It is proprietary software that costs $35 versus the free Anki; however, it has some unique features that I like.

The interface is simpler than Anki, and I've found it to be less buggy. I'm all about simplicity. You can also enter in cards into notepad, which can then be transferred to the queue for adding cards into the SRS. You can learn the programming tags such that you even add images/sound/formatting using this input method too. I find this faster than using the user interface to enter information, and useful when I don't have access to the program.

It uses an ANN (artificial neural netowork) for its algorithm, which I believe is potentially more powerful because it should theoretically adapt to one's specific memory.

I wish it used Anki's tagging system in parallel with its hierarchical category system because I find both useful. Because it uses a knowledge tree to organize the cards, you only have to maintain one database/"deck". I find that much more manageable than maintaining multiple decks. If you are limited on time you can add/review cards based on a specific category, which I find incredibly useful.

Tagging would make searching faster and more specific, and would make the software's ability to limit reviews and card additions more useful. Plus in reality, knowledge can really be cleanly divided into one or another categories.

Hey,Thanks for the compliments and the comments. You're clearly an SRS zealot like me :) You're going to crush med school when you get there. I wish I knew about SRS in college. I did well enough with my more traditional methods (see Study Skills) but I still forgot a lot semester after semester. If I had had the cards in college like you, I wouldn't feel like I wasted money on tuition just to forget stuff. Oh well. You live you learn.

FullRecall looks good. The ANN sounds like it'd be very beneficial. But I find Anki plenty simple to use. And the mobile app is great. And I think the tag and selective study features are essential. Anki 2.0 is coming out soon and will have a lot of improvements and new features. You can try the alpha version out if you go to ankisrs.net.

Either way, what matters is that you actually use the cards. And whatever program lets you do that is the one that is best for you.

Good luck. Let me know how med school goes. Shoot me a line if you need guidance.

Dr. Willbe, I just had a question how your card rating interval. How many days apart was each number, 1-4/difficulty? I know Anki is based on Spaced repetition but is there a specific effective spacing interval? Thanks

Hi,Are you referring to the initial intervals when you first learn a card? I use the Anki defaults. it's usually like 1, 3, 5 days. But after that, the intervals are based on how easily you answer the card. I don't do anything to manipulate the intervals. I leave that to Anki.

(1) See note above. The microbio media are corrupted. I'm sorry. It was somethign with dropbox and it ruined all my own media. So I don't have images either.

(2) I wish there were a way to make suggestions card by card, but as far as I know, there is not. What you can do is export your improved cards and put them on dropbox and post a link, like I did above. You can post it right here in the comments thread. Then others can DL those cards and import into their own decks. That's the best we can do for you.

You mentioned that you only do a maximum of 100 cards per day. Is this number based on one subject, or is it your combined total. For example, if your taking patho, and micro, at same time, would you make at most 100 cards for each, or 100 total per day?

Hi,I think 100 is the upper limit for the cumulative number of new cards/day. So all your subjects combined. try to space out your reading and card making such that you don't have to make and review more than 100 new cards/day. I know sometimes that's not possible and you will make more cards or do more new cards than that, but small, incremental steps are superior to big loads of new cards at once, I think.

Hi, Dr Willbe!I just stumbled upon your blog and I love it! I've always been interested in learning techniques and how to maximize recall. It seems a such shame that we spend so much time learning things in med school that we end up forgetting anyway.

After reading this I downloaded Anki and your flashcards, so thank you for that:) Am looking forward to getting started. I'm having trouble adding the media files though... are we supposed to add them to the flashcards individually or is there another way?

Re: media... The media are already in the cards. You just need to DL the media folder (which has the individual files in it) and keep it on your desktop. Your documents folder should have an Anki folder, where the Anki files are kept. The media can also go in there. So just DL the media and put the file in the Anki folder. Hope that helps.

Hey WillBe. I've been using your Pathology deck as a supplement to Pathoma/FA/UWORLD and I have to say I'm pretty pleased. My Path average is 78% in UWORLD. And I barely scraped by with a B in my path class. So it's definitely helped! Thanks a lot!

As a guide to other people who might use these for their dedicated USMLE study time. With about 6 weeks out from my test. Each day I watched the Pathoma videos for one chapter. I used the study options to study only the cards associated with the chapters I studied and slowly built up. This was around 300-400 cards a day, give or take a few hundred depending on the section. It can get a little daunting when those reviews start to pile up, but it has been worth it. I've also used flashcards from Shared Anki decks for First Aid (Search "FA10" if interested). I usually do about 2700 flashcard reviews per day. That usually takes me 6 hours or so, but that leaves me time to do 2 blocks of questions. And I make a Anki deck of missed UWORLD questions

WIll you kindly explain how to view your media files with their accompanying anki cards? I've downloaded the appropriate files to my desktop but unfortunately I can only see the text clipping symbol where you've included images. Thanks.

Hi. DL the media folder to your desktop. Then go to your computers document folder. There should be a folder called Anki. You'll see card files in there. Drag the medi folder into that Anki folder. You should be good with that.

Hey, Awesome deck. I was hoping to ask if there is a way to use the deck by subject. I think the info in the deck is phenomenal however it would be really difficult to use I can't control which subject to study.

Awesome! I'm happy you like the cards. Do you mean you want to study particular subtopics within a larger topic? For example, in the pathology deck, you want to just focus on cardiac or renal? I tagged all the cards by system or chapter. You need to use the selective study function (the clock button) to pick which cards you want to see. Check out the demo videos at ankisrs.net for more info.

Dr. Willbe,Like everyone else, thank you so much for sharing your decks as well as for all of the insight about how you use anki. It is truly invaluable, and I really hope to be able to incorporate your methods of study because they make so much sense. That said, I was wondering if you had any advice for someone who attends a program with mandatory class attendance. I feel as though I just won't have the time to plow through the books as I would like if I am in class all day.

Mandatory class can be a pain. We all have to battle it to some extent, but for some schools, there is just so much and it eats up all the time.

Unfortunately, you gotta work with what you've got.

You're right, trying to read while in class can be difficult. So I don't do it. We have our share of mandatory class here, and when I'm forced to show up, I spend that time for Anki review. Reviewing cards takes less mental energy for me than reading a book. You can start and stop reviewing without losing your train of thought. Also, you can do it without attracting much attention to yourself on your iphone or ipad or droid.

So what I suggest is to spend your time outside of class making a really targeted, high yield set of cards that are valuable to you. First Aid might be a good source for that. You gotta learn that stuff anyway, and there is no way that FA won't also help you with regards to your class stuff. Make your cards outside of class when you're doing w/e studying or reading. If you use lecture slides to learn, don't make cards for them (too much time and you won't care to remember that stuff anyway) but have FA alongside and make cards for the facts that align with what you're covering in class.

Then, when you're in class and you're spacing out from lecture, do your daily card reviews.

Hope that helps. It sucks that we have to come up with crafty schemes to get around the obstacles that med school puts in front of our learning, but these are the rules of the game and we've got to play by the rules for now.

Thank you so much! That is a great idea...I was playing with the idea of trying to make cards during lecture, but yes, I don't think I could wrap my brain around that. But card review is pretty easy, and I imagine my decks will be growing quickly and will require large chunks of time just for review. I think this is what I will do.

I had a question about using Uworld or USMLE rx while studying pathology. Im a first year and have been told by upperclassmen to not use these question banks now as they will be extremely valuable during dedicated board studying. Is there another Qbank that can be used during Step 4 of studying path? Can it be done without questions? I dont want to find myself without a crucial tool when dedicated board studying comes along. Thanks.

I discuss this issue above. Without Anki, I would say that your classmates are right. Don't squander the good stuff by using them early. But with an SRS, you can retain and review the take-away lessons you get from the UWORLD q's. Most people do that qbank 2x anyway. My strategy has been to go through the whole UWORLD qbank once over, extract facts for future review and make Anki cards. I think that if you give yourself an ample amount of time between your first pass through the cards and your second pass (when you're studying solely for Step 1), you won't risk memorizing the questions and answering them out of pure recognition.

But if you really want to leave UWorld untouched, do Kaplan or USMLERx. Most people rank the quality and value of the available qbanks as such: UWORLD>>>Kaplan>USMLERx. Accordingly, a lot of students will use Kaplan or USMLERx during their school year studies and then save UWORLD for dedicated Step 1 study. That's sound advice too, but I didn't want to mess around with inferior material. I think with Anki to help me retain the lessons i learn from UWORLD, there is fear of 'peaking' before the right time or forgetting the lessons learned.

Thanks for answering. Being a huge fan of SRS (started using it a month into med school), the logic of using UWORLD q's is very sound. I just seem to have anxiety over breaking the traditional ways students study for step1. Out of curiosity, what would your study plan be during dedicated board time? I know most students review FA till their eyes bleed and spend the rest of their time on UWORLD. I always suspected that if I kept using Anki till then, I'd find myself not doing much else other than review FA and my anki decks over and over again - which makes me feel like I'm not doing much. Whats your take on it? Thanks in advance

I know you're a big fan of SRS, but how do you have Anki show you all of your cards every time? I spent hours making cards thinking I could thumb through them a week before my test only to find I can't easily navigate through them. Any tips?

Hey,So what you're asking to do is cram all your cards at a predetermined time. That's fine, but that's not SRS. You won't get the full benefit of Anki from that. Making a boatload of cards and then using them once or twice before a test can help you with that test but it's not good for long term retention. It's a lot of work to put in just for a test.

But to your question. There is a cram function on Anki. The way to go through specific cards is to tag them appropriately when making them (or after if you forgot). For example, say you made like 200 cards that are pertinent to Exam 3 (your upcoming exam). Give those cards the tag "Exam 3". Then go to the cram function and it will ask you which tags to select. Choose "Exam 3". Then you can cram all those cards at will when you want. If you want to break it down even more, add more tags that are more specific. So say 20 of those cards are specifically on "beta blockers" and you just want to cram those. You can do that by selecting cards with just that tag in the cram function.

So you can do what you're asking. And admittedly, i do that from time to time before a test for some last minute review. Because what Anki says is the optimal time for review and what your class demands of you are almost never the same. What you might do if you don't have the time to put your new cards into your SR review schedule is to cram those cards you made right before a test. Then when the test is over and you get a breather, you can slowly start reviewing those cards in the real Anki review system (not cram function) so you can remember that stuff long term. Say you do like 20 new cards a day. Trying to add hundreds of cards into your review schedule right before a test is asking for trouble because you're going to get blasted with those reviews all at once (I did this last year and had days where I had to review like 400+ cards... it was ridiculous, but that's what my school's test schedule imposed on me).

Hey Dr. Willbe, I downloaded your decks and I absolutely LOVE them!!! They have the appropriate amount of information & the major have pictures associated (Im a great visual learner, so this helps me a ton!)But here is my dilemma, I am taking Step1 near the end of July and the question that I have is how long do YOU think it will take to get thru the Pathology, Physio, and BioChem decks in addition to watching Kaplan High-Yield Videos (Scheduled to finish June 20) & Pathoma Videos. But if I am in a time crunch I will just do Path-deck I really need a 235+ to be competitive for Ophthalmology.

In ending, I would like to say, "Thank You" again for the wonderful decks that you have graciously shared with the world

I am going to try your method soon! I have failed the Usmle exam and I am going to give it one more try. I failed by not remembering easy recall material. Simple easy answers that slipped my mind due to the stress of the big exam. I have gone through all the review programs kaplan, pass program, pathoma, all qbanks usmle world, usmlerx, and kaplan qbank.

I am going to combine my medical study with you flash cards. To keep me on my toes and to keep me focused. Thank you again for creating these!

Hi, Sorry you've had a rough time. It sounds like you've exhausted a lot of options. To be sure, you gotta memorize some basic facts to understand questions. But with all the resources you've used, I'm surprised that wasn't enough. Anki can definitely help you keep the info in your head, but it depends on your time frame. DO NOT USE THE CARDS AS YOUR ONLY RESOURCE! You still need to do all those qbanks. The cards are supplementary. Let me know how you fare.

No worries your Anki desk has helped me no doubt but it is not my sole source of study.

I am doing about 50-100 questions a day from qbanks.Then I am doing about 100 Anki cards from your deck.I am annotating everything in my first aid. I am going through your anki deck and rereading in my first aid and most of your Anki deck is on point with the material I am seeing in first aid.

Then I am going about my daily material. Right now going back to the concepts of basic sciences. So going through costanzo physiology and using your Anki Deck along with qbanks to reiterate my knowledge.

In my free time I am using a random selection of your anki deck to keep me from forgetting other material since I have studied extensively all the medical material before.

I have maybe 5-6 months before I retake my exam so I hope this time it counts!

Thanks for sharing this deck sir! I wish I had this before I even started studying for step 1!

Hi. The decks I share in the link above have uworld questions integrated. The micro, path and pharm decks in particular. I don't tag them or mark them as uworld, but they are in there. My addition of uworld material was selective. It's not everything at all. I only added stuff that wasn't in the deck already.

I'm in my second week as an M1 and I'm having a tough time with my metabolism class. The syllabus and the lectures are quite disparate, disorganized and full of useless information. I have purchased First Aid for the Basic Sciences, General Concepts and am using it to help discern the important material. I'm sold on the idea of Anki and have begun to use it, but I have one question you might be able to help me with. How do you keep track of what sections of each book/lecture/syllabus you have made cards for? It can be quite a task to try to keep it all straight. Thanks for any pro-tips you can give!

Welcome to med school :) Land of the disorganized, disparate and useless (at times). I think it's a good move that you've decided to use those FA resources. Why not just plain old FA for Step 1? There is great overlap to be sure, but if you really want high yield, that's where it's at.

With regard to keeping cards straight, use the tagging function! There is a field at the bottom of each new card to add a tag. Tag your cards according to topic, chapter, lecture, whatever will help you best. Then you can do a "Selective study" and only study the cards with certain tags. This will help you, say, only see cards for your upcoming exam, or only the ones pertinent to the chapter you just read.

I decided to go with FA general principles for a couple of reasons. First, FA 2012 is just not their best effort. It's chock full of errors and is generally hated, so I'm going to wait until 2013 comes around with my fingers crossed. Second, FA is great if you already have a solid foundation, but that is exactly what I'm trying to build. FA-BSGP is basically a textbook for the whole first year, and it does a fantastic job of explaining the important things from the ground up while making clinical correlations and weaving together different concepts. I think that using FA-BSGP for my first year will help me wrap around everything and do well in my classes, which is my primary focus right now, but come second year I can just suspend the low-yield cards and add in the key facts from regular FA.

Great idea with the tagging. I talked to my girlfriend about it and she had an idea that would work really well with that: I could make a "table of contents" of sorts, and break my classes down by "Class -> Chapter Topic -> Subtopic", further tagging information found *only* in my syllabus as "... -> Syllabus Only." This way, I could help keep track of information that seems pertinent only for my particular class, and could think about removing it down the road.

Keep up the good work on this blog! Good luck studying for Step 1, I'm very curious to see how you do after using Anki for two years!

HI Dr.Willbe,I just found your site, Thanks alot for sharing your hard work with the world , Truly Selfless! you have got down the first quality of becoming a Doctor ! Bravo!so this might sound weird but frankly iam sort of a computer novice , and often have trouble with new programs and applications . Prefer the Old school pen and paper/bound books etc. Just heard about Anki from your blog and was intrigued, even excited to try a computer application to help with learning .

So, my problem is , i went through your post and downloaded Anki onto my desktop. Then i went to drop box and downloaded your files as zip files, now , what next?how do i view them through Anki ? how do i open the individual files?sorry it must be a little annoyimg to teach someone ABC.

but any help would be greatly appreciated .

Thanks in advance and Thanks Alot !!!! for all the Info you have shared through your blog !!!!Sam

so, just an update , after what i tried to figure out , i opened Anki , went to ' files' then > download then> shared decks and then i put in 'pathology' in the search panel .... and so many pathology folders turned , was confused which one was yours and so did not downlaod any .just have to know how to view your files after i have downloaded your files from droppbox ?Thanks again !!Sam

Hi Dr.Willbe first of I want to wish you best of luck on your upcoming usmle test. I think you mentioned in one of your forums you are taking it soon.

Anyways I wanted to ask what is your studying approach while you are doing anki? Like how many anki cards do you do a day? Approximately how long does it take you? Do you repeat the card if you get it wrong?

I have been using your decks for the last 2 months adding pictures whenever I can from google and taking excerpts from the 2012 first aid. I can say I review 400-500 anki flash cards a day. This is the fast pace I set for myself because I hope to take the exam by march. I do every subject each day you have in your deck without fail. Then I do a block of question and finally go over the subject for the day. I really hope it pays dividends for me on the exam =)

Hey Man a big THANK YOU for your anki decks. I was making anki cards out of goljan and it took me a long time but now that you have made them it will save me a lot of time for the steps. You are AWESOME!

Anki or not to Anki?A fellow 2nd year student here.I am technologically challenged and was making physical flashcards during the 1st year .But this is impossible in the 2nd year. i downloaded the anki software - and then went to the dropbox to download the pathology folder.But when I copied and placed the folder in the media file in anki folder , and tried to import it- it says it does not recognize it. Is this due to the new version of anki?I have uninstalled anki from my desktop.Could someone please give me a detailed step by step instruction for downloading anki, installing and then importing the media files?Btw thank you all for sharing your comments and thoughts. I really think using this technique will help us become better physicians in the future.

Once you do that, download both the anki deck file AND the media folder. Put both the Anki files and the media in the "Anki" folder in your computers "Documents" folder.

Then, go to Anki and go to file > import and select each deck (not the media, but the deck file) that you want to import. The media will be packaged along in there. You don't need to do anything to the media other than have them in your folder.

That's it.

If you need more help, I recommend the Anki manual and the videos.http://ankisrs.net/docs/manual.htmlhttp://www.youtube.com/watch?v=QS2G-k2hQyg&feature=plcp

Hey,I like your methods. You and others who visit this site might consider using the templates I have made using conditional statements to make multisided cards. A video I made on how to use Anki in this way is posted here https://www.youtube.com/watch?v=3XkLculr7_Y&feature=plcp ; let me know what you think.

Nice videos. Your method is good, albeit a little time consuming. Have you seen the shared decks on Anki Web? Some medical students from U of Nottingham in the UK put out two amazing anatomy decks based on Gray's and Netters that use exactly the same principle. It might save you a lot of work.

You deck is amazing! It is fully detailed and makes learning effortless & fun!

Since starting anki a few months ago my nbme scores have all increased by an average of 20 points!

I can attest that Anki really works!

A helpful hint to all of those already using anki download a pdf version of First aid or any resource you may want and copy and paste a snippet next to the answer. This way when you answer the question you can go ahead and reread that part in first aid to get the full picture.

I also add pictures from google, webpath or any place to help me visualize what I am learning.

Trust me if you were stuck like I was studying massive amount of material spending countless hours watching videos doing questions etc. Anki makes learning so much more efficient! I wish I did this before...

Now I must say you won't see the full benefit in the first or 2nd months but I would say after the 2nd month I saw a huge difference!So be persistent and stick with it! I have not missed a single review day in my months of study so anki also provides you with discipline! If I miss one day my reviews rack up so in order to avoid this I must be consistent everyday! I don't mind at all because anki makes learning fun and enjoyable instead of forced study.

Best of Luck guys! Again thanks again Dr. Willbe your decks are some of the best I have ever seen!

Hey Dr.Willbe thank you for the reply! Congratulations on your usmle score!! You helped out so many people with this deck glad to see you got the score you wanted! PS I think your deck is getting more famous its been really highly regarded on www.usmleforum.com

So again many many congratulations and thanks!

One last thing have you already started to make a deck for step 2?If so would you please post your full step 2 anki deck online? Your step 1 deck is so complete! You used every amazing resource out there! I am in love with all your anki decks. Pathology, Physiology & Pharmacology in particular!

HiI really want to start using Anki, but am lost.Can anyone please let me know a few things1) When you download the images from the folders- are you just downloading images or are they flashcards?2) I have tried to download the files and upload them to anki but failed to do so :(3) Do you guys have decks that you might want to share? That way I can look at some samples and create my own.

Btw, I am really struggling with the vast material in medical school and think that the digital flashcard is the way to go.Thanks If anyone wants to email me directly.steven.orlando@aol.comThanks :)

Once you do that, download both the anki deck file AND the media folders that are in the droxbox folder on the front of my blog page (which I assume you've been to). Put both the Anki files and the media in the "Anki" folder in your computers "Documents" folder.

Then, go to Anki and go to file > import and select each deck that you want to import.

That's it. There are shared decks for Anki that you can access. They are on Anki Web, which you can access after you've signed up for a free account. I think you should read the Anki 2 manual first. This will answer a lot of your questions.

First, thanks so much for putting all of this together! I am also a big fan of Anki and have been using it throughout med school. I am now in my second year and have been using a similar deck that was just First Aid along with my course material and many of the other resources you cited.

My question is, I downloaded your deck and am trying to set it up so that each Pathology section has a subsection, such as "Medicine::Pathology::Cardiovascular System", so that I can use it in a more systematic way rather than just plow through from the beginning. Is there any chance you've already tagged the decks in a way where I can shift them to this style? I've tried doing it for a couple decks, but there are so many different tags it seems a bit cumbersome...Any help would be greatly appreciated!

My path deck is already tagged like that actually. It's by system. So you should be able to study like that. In general though, if you want to tag other people's cards in a coherent way, you'd need to use the browser to search for all cards related to your topic (say cardio). That might take some time, since you'd need to use a lot of different terms. Then you'd need to add your own tag.

I was able to take the time today to convert the tagged cards to their own subdecks for pretty much all of pathology and pharmacology. I find that it fits the scheme of Anki 2 better than just tagged cards. If you're interested, I can probably send it to you so that it's available in that format for others to download. Let me know.

After you study a deck, Anki shuts you out of that deck. So, you click custom study, then what do you do to let anki allow you to study cards it thinks you already know? I've tried everything. I'm left with using up/down arrows under browse to study cards. I need a 5 min anki TA session...

I have read quite a bit of your blog. Thank you. I am a big fan of flash cards, a and bigger fan of SR.

I'm a first year med student. What do you think of starting on pathoma now? Too much to do that and keep up with 1st year material? Won't stick without the class, or time to do big picture stuff on my own?

Most people say they wish they had started Anki SR sooner, maybe this is to soon?

Thanks for you contributions to the long term recall of massive amounts of high yield info for so many of us. Best of luck in your future endeavors.

Thank you for sharing this . I'm an Egyptian student and here we study medicine in 6 years plus a year of clinical practice : Anatomy , Physiology , Histology and Biochemistry years 1 and 2 then Pathology , Microbiology , Parasitology and Pharmacology year 3 . I'm in the begining of my 3rd year and I have always been okay with hard work , I like excellence . However , our syllabus won't offer as good or as much as those you study in America or Europe . For Pathology , I'm still studying general , covered the chapter of inflammation only . I've planned to study what I've been taught in the lecture ( on same day ) with correlation to gross pictures and histopathological specimens on the same topic . I also prepare a little for the topic of the following lecture . After reading your post , I've decided to use a textbook or a wider source for information plus a book or two for questions , specially MCQs . I've chosen Pathoma as a source and USMLE World Step 1 for questions plus MCQs from any available source on the internet . Do you think there's any more I can do ? I really value the importance of Pathology as the base for almost anything medical .

Our program is the most dedicated to your success on Step2 CS. With our usmle study course it is almost impossible not to pass this test. The secret is that we have the most dedicated and highly experienced team of professionals that will guide you every step of the way.